(Buyer) Beware The Status Quo

Imagine the following scenario. You are a physician specializing in spine care. You've added an urgent consult to your medical office schedule. The patient, who lives 110 miles away, arrives after a two hour drive in early morning rush hour traffic in severe (10/10) pain. She describes a two week history of nearly disabling, excruciating left leg pain ("sciatica"). She's already seen two other physicians (a surgeon and an interventionist) who offered two very different opinions on treatment and she is looking to you for a ‘tie-breaker’. She was unable to obtain her medical records or copies of her recent spine MRI from the other physicians. Unfortunately, both outside physicians use different electronic medical records (EMRs), neither of which communicates with your EMR (yet a third brand). While the patient waits 35 minutes in the exam room, your office staff hurries to call both outside offices to request records be faxed. The surgeon's office is closed for the day (the phone message is "if this is an emergency, call 911). The other office's nurse assures you the records will be sent immediately. After another 25 minutes, the fax machine delivers the records. Of course, as you explain to the now very frustrated patient, the actual MRI images can't be faxed and all you have is a report. To deliver the most definitive and conclusive opinion, you need to see the films. What now?

a.) Ask the patient's family to make a 220 mile round trip to pick up and deliver the records and MRI.

b.) Order a clinically not-indicated, repeat MRI adding $2,500 to the cost of the visit.

c.) Provide a best-guess opinion based on inadequate information.

Of course, the correct answer is none of the above. Sadly, this is not a unique scenario. This happens everyday in our current healthcare system.

Real-time access to patient data across the entire healthcare ecosystem is the only way to truly “fix” the problems described by the story above. However, despite regulatory & policy efforts, we are no closer today to true data interoperability than we were ten years ago.

Recently, along with a number of More Disruption Please (http://www.athenahealth.com/more-disruption-please/more-disruption) partner company CEOs, I was invited to visit Capitol Hill to discuss a number of important key policy issues that affect the success or failure of our businesses. As a startup, securing such wide access to key policymakers is next to impossible. athenahealth’s Hill Day is really the only way that we can have our voices heard by those that make the important legislative and regulatory decisions. Without this kind of opportunity, the only voices being heard would be the entrenched interested (discussed below) that are reluctant to see change.

C-CDA is not TRUE interoperability

While many vendors point to mechanisms to transmit patient data such as the Consolidated Clinical Document Architecture (C-CDA) as “interoperability,” this is a low bar. As a software developer, I have written true integrations to many APIs (Application Programming Interfaces) that provide well-defined endpoints to rapidly (milliseconds) and securely access and set structured data.For example, if I wanted to write an application that coordinated the arrival times for a group of friends for a dinner reservation, I could ask the group’s smartphones for GPS data to obtain each member’s location, ask Google Maps’ API for directions, traffic data, and travel time for each, and then process a proposed departure time for each. This would be doable in a weekend hackathon. The healthcare industry still sends faxes and formatted XML documents. Think about that.

Interoperability - previously a “check box” item, now an essential part of clinical practice

Previously, purchasing an EMR that checked the interoperability box was required in order for providers to receive incentives from government to offset the cost of the implementation (through Meaningful Use). In the latest MACRA policy guidance -- a significant expansion of how Medicare providers will be paid -- leveraging technology that requires true interoperability to function will be essential. We have written two pieces recently on what MACRA is and its implications are for providers and patients alike (found here and here).

Dorsata’s core product is an example of such a technology. We do for EMR documentation what TurboTax does for navigating your tax forms -- all on a tablet. We bring logic, workflow, and intelligence from clinical decision support to the assessments, documentation, diagnoses, and orders that are ultimately packaged, coded and sent back to your EMR. Solutions like ours require that patient data not only be available in real time in the exam room, but also that data can be pushed back (in a structured way) to a variety of systems.

Ultimately, solutions like this require that policymakers and regulators rethink how they define “interoperability”. Simply choosing a single standard architecture or protocol is not enough. This opens the door to technology vendors doing as little as possible. What will solve the problem is setting qualitative guidance around what should be achieved through interoperability. This way, as cutting edge technology and protocols change, policy won’t have to struggle to keep up. The goals and objectives of true interoperability will not change even as clinical use cases for interoperability evolve.

The bigger challenge is overcoming the other side of the market, which is made up of large, entrenched providers of monolithic, legacy systems that ardently oppose strengthening -- qualitatively -- the regulatory definition of true data interoperability. It’s this bar that prevents startups from carving out modular niches in oft-maligned areas of EMR systems and delivering innovative, order-of-magnitude improvements. If true data interoperability was actually in practice, it would be simple for providers to drive a best-in-breed strategy for certain aspects of their workflow.

Don’t be Siebel Systems

The cost of building and bringing high-quality, scalable solutions to market have never been lower, and the barrier to standing up a software application and iterating it with the direct input of your end users is almost non-existent.

Legacy vendors that believe they can prevent their customers from embracing a “best of breed” strategy that leverages innovative solutions to solve specific pain points have been shown time and time again to be wrong. Eventually, a major market shift that alters the customer landscape will force them to adapt or die. Siebel Systems is always cited as the classic example. Bruce Cleveland (a founding senior executive at Siebel) dissects what happened in his piece “Lessons from the death of a tech goliath.” Ultimately, what killed Siebel was an over-reliance on large enterprise customers whose margins were squeezed during the global recession that followed the tech crash of 2001. $100m contracts were the first things to be slashed and Siebel was not prepared, nor equipped, to adapt rapidly. We should not kid ourselves that hospitals and large health systems are immune from this. Two key pieces of advice from Bruce’s article:

“Beware the Status Quo” - market forces are not fixed. They are fluid and incredibly dynamic. In 20 years we will wonder why software ever cost hundreds of millions of dollars to buy, implement, and manage.

“Diversity is your best shot at survival” - embrace that being a one-size-fits all solution leads to mediocre product experience. Find commercially viable ways to work with innovators that are crafting innovative solutions for providers and presenting ROI-driven pricing structures. Kudos to athenahealth for going “all-in” on this strategy.

No industry is immune from these dynamics and the threats are just as real in healthcare.

Ultimately, it comes down to everyone in the healthcare ecosystem -- large, legacy vendors and startups alike -- making hard choices because they’re the right thing to do. At the end of the day, healthcare is about keeping patients healthy and caring for the sick. We owe it to ourselves to set a higher bar for the solutions we offer our caregivers.

I welcome thoughts and comments. You can reach me any time at david [at] dorsata [dot] com.

About David Fairbrothers

David Fairbrothers is the co-founder and CEO of Dorsata, Inc. Over the past eight years, David has been involved with or led product development in seven different companies in industries ranging from consumer internet to health IT. David is an investor in several early stage technology companies including Spendrix and Ascend Fitness. He is a full-stack developer on a variety of web and mobile platforms such as Ruby on Rails, AngularJS, Swift, and LAMP. David holds a BA from the University of Virginia and was a member of the football team there.